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Adoption/Foster Care Placement FMLA Certification

I, [employee name], attest that I am in the process of __ adopting / __fostering a child. I am requesting leave under the Family and Medical Leave Act for time needed to fulfill prerequisites prior to the placement and for bonding leave after the placement of the child in my home. As per [company name] policy, I will provide substantiation below and as warranted throughout the placement process.


Employee Signature: ________________________________   Date: _________________

Employee Name [printed]: ___________________________________________________


Leave start date: __________________________________________________________

Anticipated or actual placement date: _________________________________________

If leave is necessary prior to the date of adoption/foster care placement, such as for court appearances, counseling, etc., indicate the date(s) and reason(s) below:

Reason - provide brief explanation


​Name of adoption or foster care agency: ______________________________
Address: _________________________________
Contact Name: _______________________________ Phone: _____________
Type(s) of documentation attached / to be provided at a later date:
  • Foster care/adoption placement letter.                                  

  • Adoption court documents.   

  • Birth certificate/certification of birth.

  • Adoption/foster care agency documents for pre-placement activities.

  • Travel documents. 

  • Other [explain]: _________________________________________________________

HR Use Only

​Document Received

HR Representative Signature: ___________________________________________________


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